AJSLP

Clinical Focus

Speech-Language Pathology and Concussion Management in Intercollegiate Athletics: The Miami University Concussion Management Program Kelly Knollman Porter,a Fofi Constantinidou,a,b and Kathleen Hutchinson Marrona

Purpose: The Miami University Concussion Management Program was established in 1999 to assess, manage, and monitor athletes who sustain concussions and experience neurobehavioral and neurocognitive symptoms secondary to their injury. The purpose of this article is to describe the established procedures of one of the oldest universitybased interdisciplinary concussion management programs that is coordinated by speech-language pathologists (SLP). Method: The theoretical and clinical underpinnings of baseline and postconcussion neurocognitive assessment and management procedures are discussed. Additionally, 2 illustrative case studies are presented to demonstrate the evolution and implementation of the interdisciplinary

concussion management protocol and to present different patterns of concussion symptoms and recovery. Paper and computer-based neurocognitive assessment protocols are discussed and integrated in the case studies. Results/Conclusions: Successful management of sportrelated concussion requires an interdisciplinary team that understands the unique neurobehavioral and neurocognitive symptoms associated with sports concussions. SLPs can play a valuable role on the interdisciplinary team in the prompt and appropriate management of postconcussion symptoms so that athletes can successfully return to their athletic, academic, and social activities.

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course of their athletic careers, which can increase the risk of future concussions or long-standing chronic neurocognitive effects (Dashnaw, Petraglia, & Bailes, 2012; Harmon et al., 2013; McCrory et al., 2013). Recent figures estimate that approximately 3.8 million cases of sports- and recreationrelated traumatic brain injuries occur each year in the United States; however, 50% of these may go unreported (Harmon et al., 2013). For these reasons, continued education of athletes and the public about the potential risks associated with concussion is warranted for prompt and appropriate concussion management (Dashnaw et al., 2012). Speech-language pathologists (SLPs) can play a pivotal role in concussion management because of their expertise in the assessment, diagnosis, and treatment of persons with cognitive-linguistic disorders associated with traumatic brain injury (Duff, 2009; Salvatore & Sirmon Fjordbak, 2011). Furthermore, SLPs can provide an integral and functional perspective and facilitate the work of the concussion management team. In this article, we will present information on the Miami University (MU) Concussion Management Program, an interdisciplinary team coordinated by an SLP in collaboration with the SLP Department and Clinic.

sports-related concussion is classically defined as a traumatically induced brain injury caused by contact with an opponent, a teammate, the ground, or a piece of equipment or object in the playing area, which can result in transient alterations in brain function (Guskiewicz et al., 2003; McCrory et al., 2013, 2009). Although a single concussion has been considered less severe when compared with other forms of brain injury, a second impact to the head before brain recovery may result in greater or more prolonged neurocognitive dysfunction, impacting athletic, academic, and social activities of daily life (Harmon et al., 2013). In addition, research findings suggest that athletes may incur a cumulative range of mild head impacts over the

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Miami University, Oxford, OH University of Cyprus Correspondence to Kelly Knollman Porter: [email protected]

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Fofi Constantinidou developed and coordinated the concussion program between 1999 and 2008 while on the Miami University faculty and is now affiliated with the University of Cyprus. Editor: Krista Wilkinson Associate Editor: Margaret Blake Received October 8, 2013 Revision received February 11, 2014 Accepted July 23, 2014 DOI: 10.1044/2014_AJSLP-13-0126

Disclosure: The authors have declared that no competing interests existed at the time of publication.

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Neurobehavioral and Neurocognitive Outcomes of Sports Concussion Athletes may experience a variety of acute somatic symptoms associated with a concussion such as headache, dizziness, and nausea or vomiting (Guskiewicz et al., 2003; Jotwani & Harmon, 2010). Other sequalae include but are not limited to slurred or incoherent speech, sensitivity to bright lights and noise, reduced coordination, and decreased oculomotor control and performance (Cobb & Battin, 2004; Heitger et al., 2009). Finally, emotional symptoms (e.g., depression, irritability, emotional instability, feeling of disconnection from life; Jotwani & Harmon, 2010), and sleep-related symptoms (e.g., hypersomnia, insomnia, general sleep disturbances; Breed, Flanagan, & Watson, 2004; Jotwani & Harmon, 2010) often accompany a concussion or a mild brain injury. Although similar patterns of neurobehavioral deficits can be present among injured athletes, no two have identical presentations. For that reason, injured athletes can demonstrate varying degrees of impaired performance and decision-making capacity immediately or for days or weeks after the event. Additionally, in a recent survey, 53% of athletes recalled having at least one possible concussion; however, only 48% of the suspected events were reported to a coach or medical professional (Register-Mihalik et al., 2013). This failure to relay concussive events can be influenced by intense external or internal pressures to perform (Granito, 2001; Guilmette, Malia, & McQuiggan, 2007). In addition, athletes may not believe that concussion symptoms are serious enough to report to a medical professional (Register-Mihalik et al., 2013). Lack of symptom reporting can result in premature return to play, thus increasing the risk of reinjury (Harmon et al., 2013). Therefore, concussion management teams cannot strictly rely on athletes’ report of symptoms during the recovery process. Some postconcussive symptoms such as confusion and irritability can be readily observed; however, more subtle changes in neurocognitive functioning may only be determined through formal cognitive assessment. Reductions in cognitive performance have been reported in the following areas: verbal and visual memory (immediate and delayed recall), speed of information processing, impulse control, orientation, attention, and executive function; with the most common persistent deficits occurring in verbal memory, speed of processing (i.e., reaction time) and attention (Bruce & Echemendia, 2009; Covassin, Stearne, & Elbin, 2008; Macciocchi, Barth, Alves, Rimel, & Jane, 1996; McCrea, Iverson, Echemendia, Makdissi, & Raftery, 2013; Schatz, Pardini, Lovell, Collins, & Podell, 2006; Webbe & Barth, 2003). Additionally, athletes with a history of more than three concussions were at a greater risk for deficits in verbal memory and reaction time at least 8 days postinjury (Covassin, Moran, & Wilhelm, 2013). As a result, declines in neurocognitive performance can negatively impact collegiate athletes’ abilities to perform athletically and on academic coursework for several days, weeks, or even months postinjury (Halstead et al., 2013; Harmon et al., 2013).

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Assessment of Symptoms Standard clinical imaging protocols using computed tomography (CT) and magnetic resonance imaging (MRI) are typically insensitive in detecting the subtle effects of concussion. More contemporary structural MRI methods such as diffusion tensor imaging (DTI) or functional neuroimaging (fMRI) are better able to detect the axonal injuries associated with minor concussions (Chen et al., 2004; Ptito, Chen, & Johnston, 2007); however, these methods are used primarily for research purposes and are not implemented in standard clinical practice at this time (McCrory et al., 2013). In contrast, neurocognitive and neurobehavioral testing protocols completed postconcussion have been shown to be 82% effective in identifying performance consistent with concussion 72 hr postinjury and 89% accurate in identifying control participants without injury (Schatz et al., 2006). Neurocognitive tests do not diagnose concussion; rather, they demonstrate the effects of the concussion by highlighting cognitive changes in performance. Although it is possible to compare postconcussion neurocognitive results to age and gender-based norms, the effectiveness of such tests is enhanced with established baseline data because of the subtle and typically transient nature of the injury and the athlete’s unique preinjury cognitive status. Collection of baseline data for neurocognitive and postconcussion symptom scores provides an estimation of cognitive and neurobehavioral function, which can then be used to determine recovery from the effects of concussion and henceforth be used as a factor to determine readiness to return to play (Aubry et al., 2002; Echemendia & Cantu, 2003; Echemendia & Julian, 2001; Kelly, 2000; McCrory et al., 2013; Ravdin, Barr, Jordan, Lathan, & Relkin, 2003; Schatz et al., 2006). Studies indicate that for the majority of athletes, neurobehavioral and cognitive functions return to baseline levels within 5 to 7 days post sports concussion (Belanger & Vanderploeg, 2005; Majerske et al., 2008; McCrea et al., 2013; McCrory et al., 2013). However, as many as 15% of concussed athletes experience postconcussion symptoms that do not resolve within a week, thus interfering with academic and sports-related performance (Bernstein, 1999; Macleod, 2010).

Concussion Management Guidelines The appropriate management of sports-related concussions requires an interdisciplinary team approach to assess the athlete’s readiness for return to play, prevent unfavorable consequences, and avoid the potential long-term effects of repeated brain injury. Recently, the National Collegiate Athletic Association (NCAA) established that all college athletic departments have detailed concussion management policies in place (NCAA Sports Medicine Handbook, 2012–2013). More specifically: Institutions shall have a concussion management plan on file such that a student-athlete who exhibits signs, symptoms or behaviors consistent with a concussion shall be removed from practice or competition and evaluated by an athletics healthcare provider with

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experience in the evaluation and management of concussion. Medical clearance shall be determined by the team physician or their designees according to the concussion management plan. (p. 56) The purpose of this article is to present both the theoretical and clinical foundations and procedures for pre- and postconcussion management used by a university-based interdisciplinary team coordinated by speech-language pathology. The specific responsibilities of the team members will be reviewed with the role of the speech-language pathologist highlighted. The Miami University (MU) Concussion Management Program is one of the oldest university-based concussion programs in the United States and one of the few where the neurobehavioral and neurocognitive management is coordinated by speech-language pathology. Two case studies will be presented to demonstrate postconcussion assessment and management procedures. In addition, suggestions will be made based on the lessons learned as well as facilitators and challenges of this collaborative effort, which can be applied to clinical practice.

History of the Miami University Concussion Management Program The collaboration between the Department of Speech Pathology and Audiology and the Intercollegiate Athletics program at MU developed through years of open communication and willingness to understand each discipline’s role and responsibility in the management of concussion. The program began in 1999 with the charge to provide an interdisciplinary team approach to the assessment, diagnosis, management, and prevention of the neurocognitive and physical sequalae resulting from sports-related concussions. Still today, primary members of the team include the team physician, the team athletic trainer (AT), the SLP, and the student athlete. Wertheimer, Roebuck, Constantinidou, Tursktra, and Pavol (2008), in their study aiming to identify facilitators and barriers to interprofessional collaboration, identified several of the themes that are applicable to sports concussion management, including (a) defining the nature and structure of the collaboration; (b) delineating the roles of the team members in assessment, intervention, and management of the injured athlete; (c) identifying similarities and differences in philosophical perspectives; (d) identifying barriers to successful collaboration, (e.g., scheduling conflicts and transportation issues); and (e) identifying facilitators of collaboration (e.g., institutional and programmatic priorities for the success of the interdisciplinary program, financial support by the university administration, physical proximity, and availability of team members to solve problems). Defining the roles of the professionals on the team was a key element to the MU Concussion Management Program. More specifically, the team physician directly addresses the athlete’s immediate medical needs. This includes referrals for neuroimaging and recommendations for medications to alleviate physical symptoms of concussion such

as headaches. In addition, the physician makes all final return-to-play decisions following the injury. The AT has the most direct contact with the athlete both pre- and postinjury. Most ATs interact with athletes throughout the week and have a strong knowledge of past injuries, performance levels, and the athletes’ internal drive. The AT is typically the first professional to interact with and assess an athlete immediately following a suspected concussive event. For that reason, they can provide valuable information about concussion symptoms noted immediately and during regular medical checks postinjury. Finally, the SLP on the team has extensive training in neurobehavioral disorders resulting from brain injury and coordinates all neurocognitive baseline and postconcussion testing procedures. The SLP supervises specially trained graduate students in speechlanguage pathology while they complete testing procedures, interprets all testing data, and makes recommendations following the injury to help the athlete best manage the symptoms and neurocognitive changes associated with the concussion. The SLP also recommends and coordinates the implementation of academic accommodations during the recovery process. Additional members of the team are recruited as needed and can include a neuropsychologist for behavioral–emotional and intelligence testing and an audiologist for electrophysiologic and hearing testing. During the early years of the program, MU athletes on the varsity football, hockey, men and women’s basketball, and women’s soccer and softball teams received neurocognitive and neurobehavioral baseline testing before the onset of preseason training. With the institution of NCAA guidelines in 2010, athletes from varsity baseball, field hockey, diving, and track and field (pole vault) sports have been added to the program. In addition, as knowledge concerning the effects and management of concussion increased among traditional university students, intramural club sports have also been added, resulting in a spike in the number of baseline tests in 2013. To date, over 1,000 athletes have received baseline assessments with 174 having sustained a concussion. Since the onset of the MU program, on average, 13 athletes per year (SD = 5.12) are managed because of sports-related concussion. However, the number of individuals seen for postconcussion testing in the current 2013–2014 athletic season has increased by 50% when compared with the total number of athletes seen during the onset of the MU concussion management program in 1999. Evolution of Neurobehavioral and Neurocognitive Testing by SLPs Baseline and postconcussion test batteries should include but are not limited to the assessment of informationprocessing speed, planning, attention, memory, and mental flexibility. Various forms of neurocognitive test batteries are currently being used which can include abbreviated or extensive assessments given on paper or computer (Aubry et al., 2002; Collie, Darby, & Maruff, 2001; Collins, Echemendia, & Lovell, 2004). The following sections will be used to describe the assessments used by the SLP over the course of the MU program (see Table 1).

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Table 1. Subtests and neurocognitive domain assessed using Pittsburgh Steelers Neuropsychological Battery (PSNPB) and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT).

PSNPB Hopkins Verbal Learning Test Initial Learning and Delayed Recall Trail Making Test A and B Controlled Oral Word Association Test (COWAT) Digit Span (from Wechsler Memory Scale—Revised Symbol Digit Modalities) Grooved Pegboard Test (GPT)

Neurocognitive domain assessed

Computer-based assessment: ImPACT

Verbal Working Memory, Retention and Recognition Memory Visual Scanning and Cognitive Speed, Mental Flexibility Word Fluency and Retrieval/ Executive Functioning Attention Span and Verbal Working Memory Visual Scanning, Visual Motor Speed Impulse Control Motor Speed/Coordination

Word Memory Xs and Os

Three Letter Memory Color Match Symbol Match Design Memory

Post-Concussion Symptom Scale

Subjective Reporting of Symptoms

Paper-based neurocognitive assessments. The neurocognitive assessment tasks initially incorporated in the MU concussion management program were based on the Pittsburgh Steelers Neuropsychological Battery (PSNPB) and were also subsequently adopted by the National Football League and the National Hockey League. The battery consists of well-established formal tests (e.g., Hopkins Verbal Learning Test [Brandt, 1991], Controlled Oral Word Association Task [COWAT; Benton & Hamsher, 1978], Grooved Pegboard Test [GPT; Klove, 1963], etc.) and assesses areas vulnerable to the effects of a minor brain injury or concussion. These areas include verbal learning and delayed recall, attention, cognitive speed, cognitive flexibility, motor and graphomotor speed, verbal fluency, and executive functioning. Different test forms are available for verbal memory tests and for verbal fluency tasks to account for multiple testing required for sports concussion management. Table 1 lists each assessment in the PSNPB and the neurocognitive area associated with each test (Lovell & Collins, 1998). In addition to the objective neurocognitive tests, two questionnaires were included in the MU assessment protocol. The Concussion Questionnaire, originally developed to survey the incidence of concussion in rugby players, was adapted from Geffen, Hinton-Bayre, Geffen, and Geffen (1998). The questionnaire consists of 28 questions regarding the participant’s history of concussion. The second questionnaire is the Post-Concussion Rating Scale (PCRS), modified by Lovell and Collins and (1998), to rate the neurobehavioral symptoms of concussion. The PCRS provides a standardized procedure to organize a player’s subjective symptoms after concussion. The PCRS is easily understood by athletes as it uses common terms to describe symptoms rather than medical terminology (e.g., sensitivity to light rather than photophobia; Schatz et al., 2006). The rating scale currently used at MU consists of 21 symptoms associated with concussion. Athletes rate their symptoms using a 7-point Likert scale with possible scores ranging from 0 (symptom not present) to 6 (symptom is severe). As this scale is based solely on self-report of symptoms, it is difficult for

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Symptom Scale

Neurocognitive domain assessed Verbal Recognition Memory (learning and retention) Visual Working Memory, Cognitive Speed and Impulse Control Verbal Working Memory and Cognitive Speed Impulse Inhibition and Visual–Motor Speed Spatial Recognition Memory (learning and retention) Subjective Reporting of Symptoms

the athletic or medical professional to ensure that this subjective report is reliable. High symptom scores have been found to be negatively related to neurocognitive performance and to predict fMRI blood oxygen level-dependent signal changes in cerebral prefrontal regions (Chen, Johnston, Collie, McCrory, & Ptito, 2007). The combined objective and subjective measures are used as part of the baseline and follow-up testing with each athlete in the MU program. The paper-based diagnostic tools discussed above can be used by the SLP during baseline and postinjury testing protocols. However, lack of symptom reporting by the athlete immediately after the injury can result in premature return to play, thus increasing the risk of reinjury (Harmon et al., 2013; Nideffer & Sagal, 2001). For these reasons, an additional paper-based assessment tool used by the interdisciplinary team includes the King-Devick (Devick, 2010) Sideline Concussion Screening Test. The King-Devick screen measures the speed of rapid number naming (reading aloud single digit numbers) and captures impairment of eye movements, attention, language, and other correlates of suboptimal brain function often observed in sports-related concussion while the athlete is on the sidelines (Galetta et al., 2011). Collection of this baseline data by the SLP provides the AT with a standardized measure to assist in making immediate return-to-play decisions while the athlete is still on the sidelines of the playing field. Computer-based neurocognitive assessment. As concussion testing became widespread in the United States, the developers of the PSNPB created a computerized testing protocol, ImPACT (Lovell et al., 2002). ImPACT provides greater flexibility and efficiency in establishing baseline neurocognitive measures for concussion management (Schatz et al., 2006). The MU Concussion Management Program transitioned to using the ImPACT testing protocol in 2005. Both ImPACT and the paper-and-pencil PSNPB assess similar cognitive areas (see Table 1). ImPACT consists of three main parts: demographic data, neurocognitive tests, and the Post-Concussion Symptom Scale (PCSS). The demographic section provides data on sport, medical, and concussion

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history. There are seven neurocognitive tests, which target various aspects of cognitive functioning including attention, memory, processing speed, and reaction time. Five separate composite scores are obtained from these seven tests, which include the following: Verbal Memory, Visual Memory, Visuomotor Processing Speed, Reaction Time, and Impulse Control (Majerske et al., 2008). Empirical research on the reliability and validity of ImPACT has been conducted by its developers. Data indicate that ImPACT can effectively determine change in cognitive function compared with baseline and can indicate when athletes have returned to baseline performance following injury (Iverson, Gaetz, Lovell, & Collins, 2004, 2005; Schatz et al., 2006). In addition, it has been found that ImPACT does not have the large practice effects often seen on paper-and-pencil tests (Iverson, Lovell, & Collins, 2003). More specifically, Lovell et al. (2002) used ImPACT to follow high school athletes postconcussion for one week following injury, comparing scores generated to age-matched control participants. Scores for control group participants without injury did not increase with multiple testing opportunities. Athletes postconcussion were found to perform much lower on the Verbal Memory test at 36 hr and 4 and 7 days postinjury compared with their baselines. In studies to examine the validity of ImPACT, decreased performance on the Symbol Digit Modalities Test (Smith, 1980) significantly correlated with ImPACT Processing Speed and Reaction Time indices (Iverson et al., 2004). Symptoms reported following a concussion were also significantly correlated to decreased performance on ImPACT Reaction Time, Verbal Memory, and Processing Speed Indices (Iverson et al., 2004). Schatz et al. (2006) found that the combined sensitivity of ImPACT and the PCSS (the probability of a positive test result when a concussion is present) is 81.9%, and the specificity (the probability of a negative test when a concussion is not present) is 89.4%.

MU Concussion Management Procedures As previously mentioned, the effective management of sports-related concussions requires the collaboration of an interdisciplinary team. The following sections include a discussion of the current methods and procedures utilized by the MU concussion management team. Figure 1 specifically represents the procedure implemented by the team in the event of a suspected sport-related injury. Preconcussion Education and Baseline Testing The MU Concussion Management Program incorporates the belief that the best way to manage concussions is through consistent education. More specifically, research supports that athletes are more likely to report symptoms if they have been educated on the risk associated with concussion (Bramley, Patrick, Lehman, & Silvis, 2012). Therefore, all athletes and coaches who participate in the Intercollegiate Athletic Program at MU are required to participate in education programs discussing symptoms and potential neurocognitive sequelae following concussion before the start

of their specific athletic season. All athletes and coaches are required to sign a form stating that they have been educated and will report any observed or self-perceived concussionlike symptoms to the AT. In addition to the group training, the SLP educates each athlete individually on the signs and possible symptoms of concussion before the completion of neurocognitive baseline testing. The SLP on the Miami University Concussion Management Team has extensive training and clinical experience in the assessment and treatment of individuals with neurocognitive impairments. Before the start of the athletic season and with the assistance of the AT, the SLP coordinates neurocognitive baseline testing for all incoming varsity athletes who are at risk for concussions. The baseline testing protocol includes ImPACT, GPT (Klove, 1963), PCRS, COWAT (Benton & Hamsher, 1978), and the KingDevick Screen (Devick, 2010). All baseline testing is completed when the athlete is rested and has not participated in high-impact physical activity before testing. In addition, testing is administered individually in a quiet distractionfree environment. Although institutions may be encouraged to complete computer-based neurocognitive baseline testing in a group environment to save time and costs, research supports that baseline testing is most reliable when completed individually and while being monitored by a trained administrator (Scolaro Moser, Schatz, Meidzwski, & Ott, 2011). At MU, baseline testing is completed by trained graduate students in SLP under the supervision of the certified SLP. These students monitor the athlete throughout testing and document any signs of test confusion or behaviors that suggest the athlete is purposefully sandbagging results. Postconcussion Procedures Procedures for the management of concussion were developed to provide maximum efficiency and to capture the effects of the injury as soon as possible after the event. If it is suspected that an athlete has sustained a concussion, they are immediately removed from play and are first managed by the AT who assesses the athlete’s immediate medical needs. Once the athlete is medically stable, the AT administers the King-Devick screen (Devick, 2010), and cranial nerve and balance testing to determine whether the athlete exhibits concussion-like symptoms. If the athlete exhibits signs of a concussion, they are removed from the playing field and referred to the team physician. The athlete is seen by a physician either while on the field or within 24–48 hours following the injury. Neurocognitive and neurobehavioral testing—The SLP team. Within this same time frame, the athlete is referred to the SLP team by the AT for postconcussion neurocognitive testing. The AT relays details to the SLP regarding the athlete’s injury. This information includes but is not limited to the (a) date and time of the injury; (b) location of the injury (e.g., helmet-to-helmet hit to the right temporal region); (c) progression of postconcussive symptoms immediately postinjury and during subsequent medical checks (e.g., loss of consciousness, confusion, amnesia, denial of injury, King-Devick score); and (d) prescribed medications to

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Figure 1. Miami University postconcussion assessment protocol. SLP = speech-language pathologist; COWAT = Controlled Oral Word Association Test; GPT = Grooved Pegboard Test; PCRS = Post-Concussion Rating Scale.

alleviate symptoms (e.g., acetaminophen for headache). This information is used by the SLP to determine consistencies and inconsistencies between the AT report and the athlete concerning the events and symptoms postinjury. Ideally, the postconcussion neurocognitive assessment administered by the SLP team takes place within 24–48 hr following the referral. The testing protocol uses the same diagnostic assessments administered during the baseline assessment, minus the King-Devick screen. All diagnostic procedures are completed in a quiet distraction-free environment by a trained graduate student in SLP, with supervision. The session begins by asking the athlete specific questions about the suspected injury, symptoms through the PCRS (e.g., immediately postinjury, 24 hr after, and current), and

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specific questions relating to academic performance. The athlete then completes the GPT, COWAT, and ImPACT. Following testing, the athlete is again asked to complete the PCRS to determine whether greater postconcussion symptoms were reported following the diagnostic procedure. The SLP team is trained to closely monitor the athlete’s behaviors and responses throughout the testing process, to document any inconsistencies in reported symptoms, and to observe behavior consistent with mental and emotional fatigue, anxiety, frustration, disorientation, confusion, or failure to comply with testing procedures. Testing can be completed in less than an hour with the analysis of results completed immediately after testing. In all cases, analysis is completed by the certified SLP in

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charge of the program. During analysis, all information obtained from the testing protocol is considered equally and is compared with the athlete’s individualized baseline performance levels. If scores on any section of the neurocognitive test battery deviate at least 1 SD from the preestablished baseline (or the national average if baseline was not obtained) or if there is report of any concussion-like symptoms, the athlete is educated by the SLP regarding test results and is provided individualized recommendations on how to best enhance the recovery process and compensate for current cognitive limitations. More specifically, during the initial stages of recovery, athletes are encouraged to refrain from physical and cognitively strenuous activity. This recommendation is based on past research suggesting that heightened physical and cognitive activity following a concussive event can impact symptoms and delay neurocognitive recovery in athletes (Majerske et al., 2008; McCrory et al., 2013). The SLP makes recommendations for each athlete based on their own unique set of symptoms and neurocognitive deficit areas (see Figure 2). Factors that may influence recommendations can include severity of symptoms reported, degree of deviation from baseline neurocognitive scores, and number of previous concussions. Postconcussion management. Neurobehavioral and neurocognitive symptoms experienced following concussion can negatively impact academic performance to varying degrees based on the severity of the injury and prior concussion history (Halstead et al., 2013; Harmon et al., 2013). Because collegiate athletes are part of an academic organization in addition to the concussion management team, their professors are also notified of the injury. Specifically, the SLP notifies professors and specifies the need for special classroom accommodations, following written approval by the athlete (see Figure 2). Academic accommodations can include (a) postponement of exams; (b) extended time given to complete exams and assignments; (c) use of a quiet distraction-free environment for exams; (d) preferential classroom seating; and (e) modifications to the classroom

environment because of noise and light sensitivity. In addition, athletes are directly encouraged to take additional rest periods during the day, refrain from activities in loud or distracting environments, and refrain from excessive electronic gaming activities. The initial recommendations provided by the SLP are maintained until the athlete can be reassessed, approximately 5–7 days after the concussive event. Between the time of initial postconcussion assessment and reassessment, the AT monitors the athlete daily and notifies the SLP and physician of any change in level of function or report of symptoms that may warrant earlier or delayed reevaluation. Following reassessment, if the athlete reports no postconcussion symptoms and if neurocognitive test results are consistent with baseline measures, recommendations are made to allow the athlete to gradually increase their level of activity with close monitoring by the AT. At that time, the AT monitors the athlete physically (e.g., balance) and behaviorally (e.g., concussion-like symptoms) while they perform low-impact physical activity. If the student athlete reports an increase in symptoms when physical activity resumes, they are referred back for further neurocognitive testing. Management of persistent postconcussion symptoms. Although the majority of athletes return to preinjury baseline status, some may present with persistent symptoms for weeks or months postinjury. When this occurs, the SLP maintains active communication with the athlete and MU faculty to continue the use of extended academic accommodations previously discussed. In addition, compensatory techniques such as use of external attention and memory aids are recommended to ensure academic success. If symptoms persist for longer than 3 months, the athlete is seen for a more comprehensive evaluation by the SLP and possible referral to a neuropsychologist for a comprehensive assessment including psychosocial testing. On the basis of the assessment results, the MU clinic develops an individualized therapy program for the treatment of persistent memory and

Figure 2. Recommendations postinjury.

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attention problems through the use of hierarchical strategies (Marshall, Bayley, McCullagh, Vlikonja, & Berrigan, 2012).

Case Studies The following case studies were selected to illustrate the implementation of the concussion management procedures and outcomes. The first case is an example of an uncomplicated, typical sports concussion. Testing incorporated noncomputer-based methods of neurocognitive testing for the management of concussion. The second example is considered a more complicated case because postinjury symptoms lasted more than 10 days (Makdissi, Cantu, Johnston, McCrory, & Meeuwisse, 2013). The second case incorporated computer testing through ImPACT along with paperbased neurocognitive testing. Both cases illustrate successful resolution of postconcussion subjective and objective symptomatology and demonstrate the use of neurocognitive and behavioral management methods in sports concussion. All methods and procedures were reviewed and approved by the MU institutional review board.

Case 1: D.P. Case 1 is about a 21-year-old male collegiate football player who had no previous history of concussion. The athlete sustained an injury during the first quarter of a game resulting in a knee injury and loss of consciousness for a period of approximately 30–40 s. According to the AT, the loss of consciousness resulted from the overall jolt of impact and not because of a direct blow to the head. The athlete was immediately removed from play. The following symptoms were reported by the athlete immediately following the event: disorientation (10–15 min), severe balance disturbances, drowsiness, fatigue, sensitivity to light and noise, and irritability. He also reported a headache, nausea, nervousness, feeling more emotional, slowed down, and mentally foggy, difficulty concentrating, and difficulty remembering. Postconcussion neurocognitive testing. Postconcussion neurocognitive testing was completed 2 days following the event by the SLP team. At that time, although some of the subjective symptoms improved, D.P. continued to report significant postconcussion symptoms (e.g., moderate– severe: mental fogginess, feeling slowed down, difficulty concentrating; moderate: drowsiness, difficulty remembering). Objective testing revealed a decline of about 2 SDs as compared with baseline scores in speed of processing and mental flexibility as measured by the Trail Making Test B. In addition, performance on visual attention and scanning, word fluency and retrieval, motor speed and coordination, and auditory memory was 1 SD below baseline as measured by the Trail Making Test A, COWAT, GPT, and Hopkins Verbal Learning Test (Brandt, 1991). On the basis of these subjective and objective findings, the SLP recommended that he refrain from all physical and cognitively strenuous activity. In addition, special academic accommodations were implemented with his college instructors, which included the following: (a) postponement of exams; (b) extended time

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given to complete assignments; (c) use of a quiet, distractionfree environment; (d) preferential classroom seating; and (e) modifications to the classroom environment because of light sensitivity. The athlete was encouraged to take additional rest breaks during the day and to refrain from participating in noisy social activities. At 6 days postinjury, the athlete was seen for repeated postconcussion testing. Athough the athlete’s subjective symptoms had improved, he continued to report mild headache, nausea, fatigue, drowsiness, mental fogginess, and felt more emotional than normal. In addition, objective testing indicated some improvement in performance but a persistent decline (of about 1 SD) in visual scanning, mental flexibility, word fluency and retrieval, and auditory memory of words. Even though the athlete exhibited signs of improvement, it was recommended that he continue to refrain from all physical activity with academic accommodations continued. Final testing was completed 10 days postinjury. At that time, the athlete reported no postconcussion symptoms, and performance measures on all neuropsychological tests had returned to baseline levels. Table 2 provides the athlete’s baseline and follow-up test scores. Summary of findings. The tests included in the PSNPB captured changes in visual scanning, mental flexibility, word fluency and retrieval, motor speed and coordination, auditory memory, and subjective symptoms. The athlete’s performance returned to baseline levels at 10 days postinjury. Recommendations were made for the athlete to gradually increase physical activity under the close supervision of the AT. The athlete was educated regarding postconcussion symptoms and was encouraged to report any changes to his trainer as his level of physical activity was increased. No further symptoms were reported that were associated with his concussion.

Case 2: A.F. Case 2 is a 20-year-old female basketball player (forward) with a history of two sports-related concussions in high school and two during her tenure at Miami University. The most recent series of events occurred following a hit to the face in the first half of a game. At that time, the athlete did not exhibit or report signs or symptoms of a concussion. However, during the second half of the game, she sustained a hit to the right side of her head. A.F. was immediately removed from play and reported symptoms to the AT (e.g., severe headache, moderate dizziness, drowsiness, sensitivity to light and noise, mild balance problems and fatigue, and feeling mentally foggy). Cranial nerve screening performed at the sidelines by the AT was inconclusive. Postconcussion neurocognitive testing. The athlete was seen for neurocognitive testing 24 hr postconcussion by the SLP team. Computer-based testing (ImPACT) as well as verbal fluency (COWAT) and motor speed (GPT) tasks were included in the test battery. Results revealed a greater than 1 SD decline in visual motor speed and reaction time when compared with baseline test scores. In addition, although subjective symptoms improved, she continued to

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Table 2. Test scores pre- and postinjury: Case 1. Subtest Hopkins Verbal Learningb Free Recall Delayed Recall Trail Making Test A Trail Making Test B Symbol Digit Modalities Test Digit Span COWATb GPT PCRSe

M (SD)a

Baseline

2 days post

6 days post

10 days post

29.05 (3.42)

25/36

21/36c

20/36c

26/36

9 (2.21) 27.4 (9.6) 58.7 (15.9) 61.31 6.87 (1.24) 5.06 (1.46) 64 (8.75) 66.05 (10.40) 70.50 (11.10) —

7/12 15.32 s 32.30 s 49 Forwards: 6 Backwards: 4 40 Dominant: 53.1 Nondominant: 56.2 No symptoms reported

6/12 25.92 sc 56.46 sd 47 Forwards: 7 Backwards: 5 33c Dominant: 57.2 Nondominant: 67.6c Mild (1): ×3 Mild–mod (2): ×9 Mod (3): ×2 Mod–severe (4): ×3 Severe (5, 6): ×0 Total score: 39

9/12 19.00 s 45.20 sc 55 Forwards: 8 Backwards: 5 32c Dominant: 53.0 Nondominant: 54.1 Mild (1) = ×6 Mild–mod (2): ×0 Mod (3): ×0 Mod–severe (4): ×0 Severe (5, 6): ×0 Total score: 6

6/12 19.28 s 35.11 s 56 Forwards: 8 Backwards: 6 44 Dominant: 50.2 Nondominant: 53.2 No symptoms reported

Note. COWAT = Controlled Oral Word Association Test; GPT = Grooved Pegboard Test; PCRS = Post-Concussion Rating Scale. a

M and SD scores are based on test norms. bIndicates administration of alternate forms; boldface text suggests a deviation from baseline scores. cIndicates about 1 SD below baseline scores. dIndicates about 2 SDs below baseline scores. ePoint value for PCRS based on a specific symptom: 0 = symptom not present; 1 = mild; 2 = mild–moderate (mod); 3 = mod; 4 = mod–severe; 5 and 6 = severe.

experience postconcussion symptoms (e.g., moderate–severe: headache; moderate: drowsiness, dizziness). Subsequently, it was recommended that the athlete refrain from all physical and cognitively strenuous activity. Both the ATs and physician were notified of the athlete’s condition and recommendations. In addition, like in the case of D.P., special academic accommodations were implemented with her college instructors, which included the following: (a) postponement of exams; (b) extended time given to complete exams and assignments; (c) use of a quiet, distraction-free environment for exams; (d) preferential classroom seating; and (e) modifications to the classroom environment because of noise and light sensitivity. The athlete was encouraged to take additional rest breaks during the day and to refrain from participating in noisy social activities. Eight days following the original injury, the athlete was seen for repeated postconcussion testing. In comparison to her initial scores, improvements were exhibited; however, reaction-time composite scores continued to deviate more than 1 SD from baseline. In addition, the athlete reported persistent symptoms (e.g., moderate–severe: headache; moderate: dizziness, sensitivity to light, drowsiness). Even though the athlete exhibited signs of improvement, it was recommended that she continue to refrain from all physical activity with academic accommodations continued. Eighteen days after the original concussion, neurocognitive performance returned to baseline, and subjective symptoms declined considerably, although some were still present (e.g., mild headache, dizziness, fatigue, feeling slowed down and mentally foggy, and mild difficulty concentrating and difficulty remembering). Previous recommendations were maintained, and the athlete continued to be monitored daily by the AT. Communication between the AT and the SLP was systematic throughout the recovery process to verify that the

athlete remained on physical rest and continued to follow academic accommodations. Final testing was completed 26 days following the original injury with neurocognitive scores at baseline levels and resolution of all symptoms. Recommendations were made for the athlete to gradually increase physical activity under the close supervision of the athletic trainer. The athlete was again fully educated regarding the signs and symptoms of concussion and was encouraged to report any change in functioning to the AT or physician if this did occur. No additional symptoms were reported following return to physical and full academic activity. Academic accommodations were no longer required and were discontinued. Table 3 provides the athlete’s baseline and follow-up test scores. Summary of findings. Case 2 exhibits a more challenging case because the athlete’s neurocognitive performance and reported symptoms extended beyond the typical 10-day time frame (Makdissi et al., 2013). Delayed recovery can be challenging for the athlete because as symptoms improve, there may be increased self-pressure to return to previous levels of cognitive and physical functioning and hence slow the recovery process. The successful management of this athlete illustrates that the close collaboration of the team members and consistency regarding the recommendations provided to the athlete contributed to the athlete’s compliance with recommendations.

Discussion Cognitive and neurobehavioral effects of sportsrelated concussion can vary in extent, severity, and duration (Harmon et al., 2013; McCrea et al., 2013). Some symptoms can be observed physically on the field by the AT or

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Table 3. Test scores pre- and postinjury: Case 2. Composite scores

Baseline (%)

24 hr post (%)

8 days post (%)

18 days post (%)

Memory Composite (Verbal) Memory Composite (Visual) Visual Motor Speed Composite Reaction Time Composite Impulse Control Composite COWATa GPTa

78.0 (22.0) 72.0 (47.0) 48.65 (88.0) 0.58 (39.0) 7.0 24.0 Rt: 73 s Lt: 72 s No symptoms reported

94.0 (82.0) 71.0 (42.0) 38.3 (43.0) 0.77 (3.0) 4.0 34.0 Rt: 66 s Lt: 70 s Mild (1): ×8

94.0 (82.0) 72.0 (43.0) 44.47 (75.0) 0.64 (19.0) 2.0 36.0 Rt: 61 s Lt: 70 s Mild (1): ×6

79.0 (26.0) 80.0 (76.0) 50.7 (97.0) 0.55 (56.0) 4.0 43.0 Rt: 56 s Lt: 56 s Mild (1): ×5

Mild–mod (2): ×6 Mod (3): ×2 Mod–severe (4): ×1 Severe (4, 5): 0 Total score = 30

Mild–mod (2): ×4 Mod (3): ×3 Mod–severe (4): ×1 Severe (4, 5): ×0 Total score = 27

Mild–mod (2): ×2 Mod (3): ×0 Mod–Severe: ×0 Severe (5, 6): ×0 Total score = 9

PCRSb

26 days post (%) 86 (55.0) 63 (22.0) 46.95 (84.0) 0.54 (60.0) 10.0 36.0 Rt: 56 s Rt: 57 s No symptoms reported

Note. Boldfaced numbers represent > 1 SD from baseline. COWAT = Controlled Oral Word Association Test; GPT = Grooved Pegboard Test. a

M and SD for COWAT and GPT are reported in Table 2. bPoint value for PCRS based on a specific symptom: 0 = symptom not present; 1 = mild; 2 = mild–mod; 3 = mod; 4 = mod–severe; 5 and 6 = severe.

physician (e.g., loss of consciousness, confusion), whereas others can be carefully revealed through formal neurocognitive testing by the SLP. In any case, the successful management of concussion requires an interdisciplinary team approach, with professionals observing and analyzing symptoms and behaviors in a variety of scenarios and settings to make the best return-to-play decisions (Harmon et al., 2013). An interdisciplinary program requires excellent communication to provide reliable and efficient services. The collaboration between members of the MU Concussion Management Program has developed through years of open communication and willingness to understand each discipline’s unique role and responsibility in the management of concussion. The expectations and procedures implemented by members of the team should be clearly delineated and communicated at the onset of the program with the regular reassessment of procedures to determine whether changes are warranted. For example, practical aspects such as referral procedures by the AT and timely assessment and the communication of test results by the SLP to the team should be developed and consistently implemented. The team frequently faces significant challenges such as making return-to-play decisions for borderline cases or deciding whether to counsel an athlete to opt out of a competitive sport in the presence of chronic cognitive deficits because of repeated concussions. Therefore, building trust and establishing collaboration is important so that consistent recommendations are provided to the athlete. In addition, institutional commitment to the agreed-upon procedures, as well as budgetary reimbursement, is also critical to the success of a sports concussion management program. The interdisciplinary team should work to provide consistent and reliable education on the signs, symptoms, and risks associated with concussion and through the collection of baseline neurocognitive data (Bramley et al., 2012). Baseline data are important in capturing the subtle

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neurocognitive effects of sports concussion. Uncomplicated concussions typically do not result in deviations from normative data (Schatz et al., 2006). Therefore, the ability to compare the injured athlete’s data to his or her baseline data has significant clinical utility (McCrory et al., 2013). The concussion management team should work together to conduct baseline assessments when new athletes arrive on campus before the onset of preseason training. This approach has been found to be practical for scheduling and testing a large number of athletes. In addition, this ensures that athletes are tested before active play and after they have adjusted somewhat to their new life on campus. However, it is possible that some athletes do demonstrate physical and mental fatigue because of changes in lifestyle and new conditioning routines. Furthermore, some athletes are dealing with the emotional aspects of leaving home, changes in their environment, and the pressures of performing at a more competitive level. Therefore, it cannot be ruled out that for some athletes, their baseline performance is not their optimal performance (Register-Mihalik et al., 2013). Finally, it is not uncommon for healthy individuals to perform lower on one or two neuropsychological measures at a given time, and this is considered an expected intraindividual difference (Heyanka, Holster, & Golden, 2013). For all of the above reasons, postconcussion assessment for some measures may be better than the baseline performance. This supports the need for multiple assessment measures to be used and analyzed when making recommendations. As demonstrated in the cases presented, both paper and computerized test measures can be used in the management of sports concussion. Selecting the best method for assessment can depend on the clinical environment and the number of individuals seen for baseline and postconcussion tests. Computerized testing has several advantages within the collegiate athletic system. First, preseason baseline testing of a large number of athletes is possible with minimal human resource demands. Supervised graduate-level

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clinicians can be trained to closely monitor athletes during testing procedures for level of effort and report of symptoms. In addition, computer administration also allows for randomization of test stimuli to decrease practice effects for follow-up testing in the event of a concussion. Computers provide more sensitive measurements of reaction time to 1/100 of a second, whereas traditional testing measures accuracy to 1–2 s (Reddy & Collins, 2009). However, SLPs should be trained not to rely solely on electronic testing for clinical decisions. Additional traditional neurocognitive measures along with structured clinical interviews and selfrating of subjective symptoms of concussion should be implemented, especially for persistent sequelae. Paper-based neurocognitive measures can also be successfully used in concussion management where the access or ability to collect baseline measures is not possible or the number of athletes seen postconcussion is small. Once purchased, paper-and-pencil tests do not require a fee-based annual license like the computerized tasks. Regardless of the selected method of testing (computerized or paper and pencil), SLPs who will engage in sports concussion management should be trained about the needs of this population, the recovery process, and on the administration and interpretation of the testing protocol. Past research has shown that the GPT (fine motor speed) and Trail Making Test A (motor speed, visual attention, graphomotor abilities) were the most sensitive measures in detecting deviations from the baseline (Constantinidou & Zimmerman, 2005). Case 1 further illustrates these findings. Similarly, visual–motor speed and reaction time (as measured by ImPACT) were also affected in Case 2. Although there may be commonalities in the patterns of concussion symptomatology among athletes, the take-home message is that symptoms can be variable. Hence, a variety of assessments measuring multiple neurocognitive areas are warranted (Register-Mihalik et al., 2013). Without proper analysis of a variety of neurocognitive, neurobehavioral, and physical measures, athletes may run a greater risk of symptoms persisting for a greater period of time or sustaining additional injuries (Makdissi, et al., 2013). In conclusion, most athletes require about 7–10 days for return to their baseline performance postconcussion (Belanger & Vanderploeg, 2005; Constantinidou & Zimmerman, 2005; Majerske et al., 2008; McCrea et al., 2013). However, as demonstrated in our second case study, some athletes with a history of repeated concussions require a longer recovery period (Covassin et al., 2013). Persistent symptoms can cause the athlete to have difficulty with academic and social activities, and SLPs can play an important role providing education and cognitivecommunication strategies during the period of recovery. At the current time, there are very few concussion management teams that incorporate SLPs into the program. However, for 14 years, the MU Concussion Management Program has demonstrated that SLPs can have a significant role in monitoring and facilitating the recovery process, thereby ensuring that injured athletes return to their preinjury academic and athletic endeavors successfully.

Acknowledgments We thank Steven Dailey for his foresight in understanding the impact of concussions on athletes and the importance of interdisciplinary management. In addition, we thank the Miami University Athletic Trainers, Speech-Language Pathology Graduate Students, and the athletes who participated in the study.

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Speech-language pathology and concussion management in intercollegiate athletics: the Miami University Concussion Management Program.

The Miami University Concussion Management Program was established in 1999 to assess, manage, and monitor athletes who sustain concussions and experie...
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